Published on February 5, 2014
Infection Control in ICU Muhammad Asim Rana MBBS, MRCP, FCCP, SF-CCM, EDIC
Why focus on infection prevention and control in critical care?
Intensive care units (ICUs) 10 %of total beds, more than 20 percent of all nosocomial infections are acquired in ICUs. ICU-acquired infections account for substantial morbidity, mortality, and expense. Improving infection prevention and control in critical care acts as a catalyst for improvement in the rest of the hospital.
Factors contributing in infections 1. Compared to general patients, patients in ICUs have more chronic comorbidities & more severe acute physiologic derangements. 2. The high frequency of use of catheters provide a portal of entry of organisms into the bloodstream. 3. Multidrug-resistant pathogens MRSA and VRE are being isolated with increasing frequency in ICUs
Studies of ICU-associated infections Most studies of ICUassociated infections come from industrialized countries, The rates of infection may even be higher in developing countries as illustrated by a multicenter, prospective cohort surveillance study of 46 hospitals in Central and South America, India, Morocco, and Turkey.
(as reported by NNIS) Ventilator associated pneumonia (VAP) CVL-related bloodstream infections 24.1 cases per 1000 ventilator days (10.0 - 52.7) 12.5 cases per 1000 catheter days ( 7.8 - 18.5) Catheter-associated urinary tract infections 8.9 cases per 1000 catheter days (1.7 - 12.8)
NNIS USA 1999 Antimicrobial Resistance VRE : 24.7 % of enterococci isolates MRSA: 53.5 % of S. aureus ESBL : 10.4 % Klebsiella 3.9 % Escherichia coli Pseudomonas aeruginosa 16.4 % resistant to imipenem 23.0 % resistant to fluoroquinolones
Risk Factors Presence of underlying comorbidities diabetes, renal failure, malignancies predispose patients to colonization and infection with multidrug-resistant bacteria. Presence of indwelling devices central venous catheters, Foley catheters, and endotracheal tubes which bypass natural host defense mechanisms and serve as portals of entry for pathogens.
Risk Factors Frequent manipulations and contact with HCWs usually concurrently caring for multiple ICU patients hands are the vehicles for transfer of pathogens from patient to patient. Long hospital courses prior to the ICU admission, More Antibiotic Exposure ,…..
Outcome of MDR ICU infections 1. Infections caused by MDR pathogens are associated with 1. 2. 3. 2. increased mortality, Increased length of hospital stay, increased hospital costs. Patients with infections due to MDR organisms usually are chronically or acutely ill and at risk of dying from underlying serious and complex medical illnesses.
Prevention of MDR Infection in the ICU Two Major Strategies 1. Strategies that attempt to improve the efficacy and utilization of antimicrobial therapy. 2. Infection Control Measures
Outline on Antibiotic utilization controls 1. 2. 3. 4. 5. 6. Antibiotic evaluation committees Protocols and guidelines to promote appropriate antimicrobial utilization Hospital formulary restrictions of broadspectrum agents Substitution of narrow-spectrum antibiotics Mandatory consultations with infectious diseases specialists Antibiotic cycling
Infection Control Measures 1. General principles of infection control 2. Specific steps involved in prevention of special MDROs
General principles of infection control Infection control a discipline that applies epidemiologic and scientific principles and statistical analysis to the prevention or reduction in rates of nosocomial infections. Effective infection control programs proven to reduce the rates of nosocomial infections and to be cost-effective. Infection control is a key component of the broader discipline of hospital epidemiology.
Achieving the main goal of preventing or reducing the risk of hospital-acquired infections Where to focus energy for impact
Functions and Responsibilities of a hospital Infection Control program Education Prevention of infections (eg, by hand hygiene) Prevention of infections due to devices disposal of infectious waste Development of infection control policies and procedures Surveillance : (hospital-wide Vs. targeted) Outbreak investigations
Functions and Responsibilities of a hospital Infection Control program Evaluation of devices used Cleaning, disinfection, and sterilization of equipment Oversight on the use of new products that directly or indirectly relate to the risk of nosocomial infections Review of antibiotic utilization and its relationship to local antibiotic resistance patterns
Functions and Responsibilities of a hospital Infection Control program Hospital employee health Pre employment assessment After exposure to either blood borne or respiratory pathogens
Areas of Infection Control Four major areas of infection control will be reviewed here: 1. Standard precautions, including hand hygiene Isolation precautions Cleaning, disinfection, and sterilization Surveillance 2. 3. 4.
STANDARD PRECAUTIONS Various forms of isolation have been used in an attempt to reduce the spread of nosocomial infections. In 1996, the CDC and Hospital Infection Control Advisory Committee (HICPAC) issued a new system of isolation precautions.
Noncritical items should be dedicated to use for a single patient if possible.
Standard precautions are recommended in the care of all hospitalized patients. The category of standard precautions combines the important features of body substance isolation policies and universal precautions, in so doing, aims to reduce the risk of transmission of infectious agents between patient and healthcare worker.
Standard precautions apply to blood, all body fluids, nonintact skin, mucous membranes and secretions and excretions except sweat.
They entail Handwashing before and after every patient contact The use of gloves, gowns and eye protection in situations in which exposure to body secretions or blood is possible Handwashing after gloves are removed The safe disposal of sharp instruments and needles in impervious containers The placement of soiled linens in impervious bags and bloody or contaminated materials such as feces or urine in sanitary toilets
The 2007 CDC guidelines included several additional components Safe injection practices. Use of a mask when prolonged procedures involving puncture of the spinal canal are performed myelography, epidural anesthesia, injection of chemotherapeutic agents. Respiratory hygiene/cough etiquette
Ignaz Philipp Semmelweis Hungarian physician (1847) incidence of puerperal fever (Lack of hand washing by clinicians) Hand dips with chlorinated lime at Vienna General Hospital. These ideas evolved to form current guidelines Hand cleansing opposed to Hand washing
Hand Hygiene The surface of the skin is home of bacteria and fungi, Resident flora Transient flora Eradicating microbes on the hands of hospital personnel is one of the holy crusades of infection control It is the single most important measure to reduce transmission of microorganisms from one person to another or one site to another on the same patient.
Organisms Isolated from the Hands of ICU Personnel Gram positive cocci Staph.epidermidis 100% Staph.aureus (MSSA) 7% Gram negative bacilli 21% Acinetobacter spp. Klebsiella spp. Enterobacter spp. Pseudomonas spp. Serratia spp. Yeasts & Fungi 16%
Cleaning vs Decontamination The removal of microbes from the skin is known as decontamination, requires the application of agents that have antimicrobial activity. Antimicrobial agents that are used to decontaminate the skin are called antiseptics, while those used to decontaminate inanimate objects are called disinfectants.
Commonly Used Antiseptics
Evidence for the efficacy of hand hygiene Comparative effects of a 6minute hand scrub with 0.75% povidone-iodine and 4% chlorhexidine gluconate on microbial growth on the hands. Bacterial counts are expressed as log base 10
Finger Nails Much of the resident microflora of hands is found in the periungual and subungual areas, and fingernails are often neglected during routine hand cleansing. When the fingernails are long and when artificial fingernails are worn, there is an increase in periungual colonization with a variety of pathogens Guidelines from the CDC and Association of Operating Room Nurses (AORN) prohibit the use of artificial fingernails or extenders by health care workers
Rings There is no consensus on the need to prohibit the wearing of rings in healthcare settings even though several studies have shown that skin beneath rings is more heavily colonized with bacteria than adjacent skin not covered by rings
Gloves Three important reasons To provide a protective barrier for the hands. To reduce the acquisition of microorganisms from a patient. To reduce the transmission of microorganisms from the hands of hospital staff to patients. However, wearing gloves does not replace the need for hand washing
Masks Three purposes in infection control To protect healthcare personnel from infectious material from patients. To protect healthcare personnel from infectious material from patients. To protect healthcare personnel from infectious material from patients. Masks should not be confused with particulate respirators that are used to prevent transmission by airborne droplet nuclei of infectious agents such as M. tuberculosis.
ISOLATION PRECAUTIONS Three isolation categories Contact: Contact precautions should be used in the care of patients with multidrug-resistant bacteria, and various enteric, parasitic, and viral pathogens. Droplet: Droplets are particles of respiratory secretions larger than 5 micrometers. Airborne spread: Airborne droplet nuclei, in contrast to larger droplets in the preceding section, are particles of respiratory secretions smaller than 5 micrometers.
Droplet Precautions Large Droplets(>5microns) Haemophilus influenza (type b) Epiglottitis,pneumonia,meningitis Place patient in a private room, if unavailable patient should not be within 3 feet of non infectious patients Hospital staff and visitors should wear a surgical mask within 3 feet of the patient Neisseria meningitidis pneumonia & meningitidis Bacterial respiratory infections Diphtheria Mycoplasma Group A strep pneumonia Viral Respiratory Infections Influenza Adenovirus Mumps Rubella
Airborne Precautions Small Droplets (<5micron) Mycobacterium TB Measels Varicella (including dissemenated Zoster) Place patient in negative pressure isolation room Hospital staff and visitors should wear N95 respirator Those who are without a history of infection or pregnant ladies, immunocompromised should not enter the room, others should wear N95
ENVIRONMENTAL CLEANING Cleaning Cleaning is the removal of all foreign material (eg, soil, organic material) from objects. It is normally accomplished with water, mechanical action, and detergents or enzymatic products. Disinfection Disinfection describes a process that eliminates many or all pathogenic microorganisms from inanimate objects, except for bacterial spores.
Sterilization Sterilization is the complete elimination or destruction of all forms of microbial life by Steam under pressure Dry heat Low temperature sterilization processes (ethylene oxide gas, plasma sterilization) Liquid chemicals
SURVEILLANCE Cornerstone of all successful hospital infection control programs. Surveillance is only the starting point and benchmark for assessing the need for intervention strategies. Effective surveillance involves counting cases and then calculating rates of various infections, analyzing these data, reporting the data in an appropriate way to personnel involved in patient care
Epidemiology and prevention and control of vancomycin-resistant enterococci
INTRODUCTION Vancomycin-resistant enterococci (VRE) are an increasingly common and difficult to treat cause of hospital-acquired infection. 2006 report from the Clinical and Laboratory Standards Institute Vancomycin susceptible — ≤ 4 mcg/mL Vancomycin resistant — ≥ 32 mcg/mL An MIC of 8 to 16 mcg/mL was considered vancomycin intermediate
TRANSMISSION VRE colonize the gastrointestinal tract and can be found on the skin due to fecal shedding. Colonization with VRE generally precedes infection, but not all patients with colonization become infected. Persons either colonized or infected with VRE can serve as sources for secondary transmission.
Transmission can occur by both Direct contact (eg, the hands of health care workers) Indirectly From instruments eg, rectal probes From environmental surfaces. The following observations come from different studies that have evaluated VRE transmission:
In a study in which VRE were inoculated in different places, the strains survived for Five to seven days on patients tables 24 hours without a reduction in counts on bedrails 60 minutes on a telephone handpiece 30 minutes on the diaphragmatic surface of stethoscopes
RISK FACTORS Previous antimicrobial therapy Patient characteristics Colonization pressure Exposure to contaminated surfaces Residence in long-term care facilities
INFECTION CONTROL Prevention of infection with VRE, requires a multifaceted approach including General infection prevention (eg, optimal management of vascular and urinary catheters) Accurate and prompt diagnosis and treatment, Prudent use of antimicrobial drugs, Prevention of transmission
Healthcare Infection Control Practices Advisory Committee (HICPAC) guideline recommendations Hand hygiene (Grade 1A) Contact precautions (Grade 1A) Cohorting (Grade 1A) Not to attempt Decolonization (Grade 1B) Surveillance cultures Not applicable everywhere three negative stool/rectal cultures obtained at weekly intervals are required to remove a previously colonized patient from contact precautions if patient is not on antimicrobials
General principles of the treatment and prevention of Acinetobacter infection
INTRODUCTION The genus Acinetobacter consists of ubiquitous Gram negative bacilli that were originally identified in the 1930s Gram negative coccobacilli non-motile, strictly aerobic, catalase-positive, and oxidase-negative.
PREVENTION AND CONTROL In an era of rising antimicrobial resistance rates and limited therapeutic options, the control of multidrug resistant pathogens such as Acinetobacter relies heavily upon preventive measures
Infection control Apply standards precautions at all times in contact with any patients Apply contact precautions with MDRO infected patients Use antibiotics appropriately In the setting of an outbreak : should be careful adherence to infection control measures. 1. Compliance with hand hygiene and should be strictly enforced. 2. Colonized and infected patients should be isolated or cohorted 3. Contact precautions should be used consistently.
Infection control (Continued) In the setting of an outbreak : Environmental surfaces 1. should be appropriately cleaned with an approved hospital disinfectant. Equipment that comes in contact with mucous membranes or nonintact skin (semi-critical items) 2. should undergo high level disinfection. Proper investigations should be conducted 3. • • attempt to identify a common source of infection to prevent further dissemination of the infecting strain
Prevention and control of methicillin-resistant Staphylococcus aureus in adults
INTRODUCTION Prevention and control of methicillin-resistant Staphylococcus aureus (MRSA) cross-infection Some European countries have managed to contain MRSA at a low prevalence Netherlands, Finland, and France the most important challenges of infection control. using active surveillance cultures contact precautions with or without decolonization Other countries: Germany and Canada did not implement early MRSA surveillance and control measures subsequently have struggled to control MRSA epidemics
SURVEILLANCE AND PRECAUTIONS High MRSA prevalence has been correlated with inadequate adherence to infection control principles; (the countries with greatest MRSA prevalence include the United States and Japan.) Active surveillance cultures (ASC) facilitate identification of patients with MRSA colonization to be placed on contact precautions The goal is to minimize MRSA spread to other patients.
Active surveillance cultures (ASC) In the setting of hospital outbreaks Among patients at high risk for MRSA infection, such as patients in intensive care units (ICUs), immunocompromised patients, long-term care facility residents, Patients on hemodialysis Patients with history of MRSA colonization Patients hospitalized in the previous twelve months Received antibiotic therapy in the last three months Patients with skin or soft tissue infection at admission
Prevention & Control HAND HYGIENE ENVIRONMENTAL CLEANING ANTIBIOTIC STEWARDSHIP COMMUNITY PREVENTION INFORMATION FOR PATIENTS
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